All posts by TheTraumaPro

The October 2020 Trauma MedEd Newsletter: Blunt Carotid and Vertebral Artery Injury

This issue is devoted to an uncommon yet potentially devastating problem, blunt carotid and vertebral artery injury.

In this issue, you will learn about:

  • What BCVI is
  • How common it is
  • The various screening systems and how good they are
  • How to grade it
  • And most importantly, how to treat it

To download the current issue, just click here!

Or copy this link into your browser: https://traumameded.com/courses/blunt-carotid-and-vertebral-artery-injury/

This newsletter was released to subscribers over a week ago. If you would like to be the first to get your hands on future newsletters, just click here to subscribe!

Cricothyrotomy In The COVID Age

COVID-19 has changed everything. Our patients and even our co-workers could be harboring the virus. Workplace precautions have changed. Many of the minutiae of living have changed. All trauma professionals are concerned with protecting themselves from contagion in order to continue providing vital care to more patients.

We have a fairly good understanding of how the virus spreads. Aerosols and aerosolizing procedures are a major risk factor for involved personnel. In general, hospitals already have processes and policies in place for the most common aerosolizing procedure, endotracheal intubation. Even in emergency circumstances, this is a relatively controlled procedure.

But what about cricothyrotomy? This is far less commonly performed, and as such is prone to more variability. Surgeons at Northwestern University in Chicago tested several techniques for more safely performing this procedure. They placed three different types of draping materials commonly found in or around a trauma bay over their hands in an attempt to decrease aerosolization produced during the procedure.

They tested these drapes using a cricothyrotomy simulator based on a porcine trachea. To identify aerosolization, they atomized fluoroscein into the trachea and monitored the procedure with an ultraviolet light.

The first drape tested was a clear plastic x-ray cassette holder. The advantage of using this as a drape is its transparency. The surgeon does not need to peek under the plastic while performing the crich. Unfortunately, the stiffness and slipperiness of the plastic makes it prone to sliding off the procedure site.

A dry blue surgical towel was used next. This performed a bit better, but still slipped off the operative field. Black light inspection showed a significant amount of aerosol contamination of the edge of the towel and the surgeon’s gown.

Finally, a wet blue surgical towel was tested. The towel easily stayed in place and retained nearly all of the aerosolized fluoroscein. There was a negligible amount on the surgeon’s gown.

Bottom line: The authors recommended that wet surgical towels be placed over their hands and used as a barrier when performing a cricothyrotomy in a COVID positive or unknown patient. The reality is that this will apply to this procedure in just about any acute trauma patient you see. Obviously, this trick does not eliminate aerosolization. Rather, it dramatically reduces the amount and hence, the risk to the surgeon and other personnel in the room. It’s not perfect, but definitely worth it!

To view a video demonstrating the technique and results for each of the drapes, click here.

Reference: Emergency cricothyrotomy during the COVID-19 pandemic: how to suppress aerosolization. Trauma Surgery Acute Care Open 5(1):e000482, 2020.

In The Next Trauma MedEd Newsletter: Blunt Carotid And Vertebral Injury

The next issue of Trauma MedEd will be sent out to subscribers this week, and will provide some interesting information on fblunt carotid and vertebral artery injury (BCVI).

This issue is being released to subscribers at 9am Central time on Tuesday. If you sign up any time before then, you will receive it, too. Otherwise, you’ll have to wait until it goes out to the general public next week. Click this link right away to sign up now and/or download back issues.

BCVI is not something trauma professionals see often. Or is it?

In this issue, learn about:

  • What BCVI is
  • How common it is
  • The various screening systems and how good they are
  • How to grade it
  • And most importantly, how to treat it

As always, this month’s issue will go to all of my subscribers first. If you are not yet one of them, click this link right away to sign up now and/or download back issues.

Everything You Wanted To Know About: Cranial Bone Flaps

Patients with severe TBI frequently undergo surgical procedures to remove clot or decompress the brain. Most of the time, they undergo a craniotomy, in which a bone flap is raised temporarily and then replaced at the end of the procedure.

But in decompressive surgery, the bone flap cannot be replaced because doing so may increase intracranial pressure. What to do with it?

There are four options:

  1. The piece of bone can buried in the subcutaneous tissue of the abdominal wall. The advantage is that it can’t get lost. Cosmetically, it looks odd, but so does having a bone flap missing from the side of your head. And this technique can’t be used as easily if the patient has had prior abdominal surgery.

2. Some centers have buried the flap in the subgaleal tissues of the scalp on the opposite side of the skull. The few papers on this technique demonstrated a low infection rate. The advantage is that only one surgical field is necessary at the time the flap is replaced. However, the cosmetic disadvantage before the flap is replaced is much more pronounced.

3. Most commonly, the flap is frozen and “banked” for later replacement. There are reports of some mineral loss from the flap after replacement, and occasional infection. And occasionally the entire piece is misplaced. Another disadvantage is that if the patient moves away or presents to another hospital for flap replacement, the logistics of transferring a frozen piece of bone are very challenging.

4. Some centers just throw the bone flap away. This necessitates replacing it with some other material like metal or plastic. This tends to be more complicated and expensive, since the replacement needs to be sculpted to fit the existing gap.

So which flap management technique is best? Unfortunately, we don’t know yet, and probably never will. Your neurosurgeons will have their favorite technique, and that will ultimately be the option of choice.

Reference: Bone flap management in neurosurgery. Rev Neuroscience 17(2):133-137, 2009.

How To: Treat A Penetrating Lung Injury

Penetrating injuries of the lung come in two flavors: gunshot and stab. However, the end result for both is the same. They leak. And the leak is either air or blood. Having lower kinetic injury, stab wounds tend not to leak as much. Gunshots, on the other hand, can travel further through lung tissue and the higher energy causes more damage.

For the most part, managing these injuries is straightforward. The lung is essentially a sponge. Since most of it is air, the amount of damage done is much less than, say, to a solid organ. But bleeding and air leaks can be annoying in some cases, and even life-threatening in others.

Today, I’ll focus on injuries to the lung parenchyma. Here’s a basic primer on how to manage them.

  1. As always, the first decision to make is to answer the question, “do we need to go to the operating room right now?” This is always determined by unstable vital signs or symptoms that cannot be controlled with simple maneuvers like a chest tube.
  2. Next, determine if any treatment is needed at all. The initial chest x-ray will tell you a lot.
    1. Is there any air or blood at all? If so, a followup chest x-ray after a set amount of hours (I use 6) will detect any progression that needs future treatment.
    2. Is there too much blood or air? If so, insert a chest tube.
  3. Is there too much ongoing air leak or bleeding? This indicates a problem (bronchial or chest wall / pulmonary vascular injury) that needs operative treatment.

What are your options if you go to the operating room? Generally, an open thoracotomy is the most desirable, especially in the face of gunshots and major bleeding. It is fast and allows for rapid and complete exploration. VATS might be okay in a few stab wounds where the injury is thought to be limited but is still problematic.

Find the hole(s). With a single penetration, there are usually one or two holes. But there can be up to four if the wound traverses two lobes. And if is are more than one penetration, all bets are off.

Don’t poke a skunk. If a particular wound has no obvious bleeding or air bubbles, leave it alone. Save your efforts for the ones that are really a problem.

Use stapled tractotomy. Direct repair of lung wounds may lead to intra-parenchymal hematomas or air embolism. Wedge resection reduces lung volume, particular in patients with multiple injuries.

Here’s how to do it. Insert a GIA stapler through the bullet tract and fire. This will lay open the entire tract so that individual air leaks and bleeders can be individually suture ligated.

Then fully evacuate all blood from the chest and make sure there is no more bleeding. Failure to do so can result in retained hemothorax and the need for yet another operation. Insert a well-positioned chest tube to finish off the procedure.

Reference: Stapled pulmonary tractotomy: a rapid way to control hemorrhage in penetrating pulmonary injuries. JACS 185(5):467-487, 1997.